Commentary

Women with cancer in low-income countries

In the 1 November issue of The Lancet in 2016, three papers and three accompanying editorials reviewed the descriptive epidemiology of breast and cervical cancer in low-income countries, highlighting the shortcomings of current efforts at cancer control and the need for improvement1–6. The authors of the three papers overlap and appear to have reached a consensus on the ideology of change. An appeal is made to the “international community” for greater financial support.

Only 5% of resources for cancer control are directed to resource-constrained countries, although 65% of deaths from cancer occur in those same countries7. When thoughts turn to the health crises in low-income countries, those thoughts usually concern infectious diseases and infant mortality; however, in absolute terms, the toll from cancer is the greatest of the three.

The three Lancet papers focus on cervical cancer and breast cancer. The authors have not reviewed other sites, such as ovarian cancer and endometrial cancer. The former two sites are natural inclusions, given their enormous burden, but the control measures for each site are very different.

In the case of cervical cancer, emphasis is rightly placed on prevention and early detection2. Cervical cancer can be prevented through vaccination against the human papillomavirus, and priority should be given to ensuring that vaccines are made available to as many young women as possible2. Cervical cancer screening is among the few cancer screening efforts that are an unequivocal success, and the authors cite studies of acetic acid staining as a tool for the detection of early cervical lesions2. An under-appreciated aspect of reported cervical cancer rates is that they are calculated for women with and without a uterus combined8. As a result, where hysterectomies are highly prevalent, the actual cervical cancer rates for at-risk women are much higher than those reported by cancer registries. Currently, an important part of cervical cancer control is hysterectomy for noncancerous conditions. If hysterectomy rates were to decline, a concomitant rise in the incidence of cervical cancer would be expected.

It is hard to make the same case for breast cancer as for cervical cancer. In breast cancer, relatively little success has been achieved in either prevention or early detection. Advising low-income women to have children early and often to prevent cancer is not a viable strategy. Links with exercise, obesity, diet, and alcohol might be statistically strong (especially for postmenopausal cancers), but the effect sizes are small, and the relevant studies are based almost entirely on Western populations. Advocating “lifestyle change” across Africa or Asia cannot be expect to make a dent in the incidence of breast cancer. Likewise, the potential for a big impact on cancer mortality through the promotion mammography in low-resource settings is unclear. The debate with respect to mammography is ongoing, and it is not certain—as it is for cervical cancer—whether strengthening screening programs will have the intended result of reducing mortality. I have previously argued in these pages that mammography might indeed be effective in low-resource settings based on the empiric relationship between tumour size and 10-year survival:

On the other hand, in a population in which cancers typically present when they are 2–5 cm and node-positive, a reduction in mortality of approximately 50% would be expected if a screening program resulted in a reduction of the mean tumour size to 2.0 cm, even if the proportion of node-positive cancers stayed the same. This situation resembles circumstances in the developing world, and it is a rational goal to try to find all breast cancers at 2.0 cm or less throughout the world.9

However, that prediction has not yet been borne out, and studies of mammography coverage and mortality in low-income countries are warranted.

Elsewhere, studies of clinical breast examination and self-examination have failed to provide enough evidence to conclude that such maneuvers could be a cornerstone of cancer control in the developing world2. There might, however, be a beneficial effect on quality of life through the downstaging of breast cancers—that is, through a reduction in the proportion of cancers that now present at advanced stages (locally and distantly metastatic).

The Lancet authors chose not to include ovarian cancer in their review. Screening for ovarian cancer is not likely to be useful, but prevention through a short course of oral contraceptives might be beneficial. Ovarian cancer poses special challenges to surgeons in the developing world. The goal in treating serous ovarian cancer should, wherever possible, be to perform aggressive surgery to reach a state of no residual disease, which should then be followed by standard chemotherapy (a platinum–taxane combination)10. Our mission should be to help surgeons establish methods for evaluating the extent of residual disease and to offer training fellowships that will aid them in achieving that goal. In setting the research agenda, it would be useful to establish, in various clinical settings, a database of unselected patients with ovarian cancer, recording the stage at diagnosis, the surgery performed, the extent of residual disease, and the eventual outcome (date of death). After surgery is concluded, the next questions to ask are how many women have access to chemotherapy and how often the standard course is completed. The compiled data could then be used to set realistic clinical benchmarks.

As a research project director or lecturer in 22 different countries in Latin America and Asia (Brazil, Colombia, Peru, Chile, Uruguay, Venezuela, Argentina, Mexico, Costa Rica, Jamaica, Cuba, Trinidad, Bahamas, China, Pakistan, Vietnam, Mongolia, Bangladesh, Philippines) over the past 20 years, I have spoken with hundreds of surgeons and medical oncologists in low-income countries. In my view, the most difficult challenge is to ensure that the interests of the physicians are aligned with the interests of the patients they serve. In many of the countries, physicians often have a public hospital position during the day and a private clinic to attend in the afternoon and evening. In the private clinic, the patient pays for care, and so there is a financial incentive to treat patients in the private clinic initially—or to transfer them from the public system to the private clinic. The purported benefits of private care are explained to the patient by the treating physician and not by a disinterested third party. It is unusual for medical oncologists to use their influence to see that the public–private gap is closed. Another important complicating factor is medical tourism: that is, offering to patients from other countries medical services that, at home, are either not readily available or are much more expensive11,12. In some cases, physicians will divert their time and governments will divert health care resources from the local population to noncitizens from abroad with the ability to pay more. Those services often include cosmetic surgery, but can include cancer treatments as well. The extent to which the expansion and marketing of medical tourism has had a direct or indirect effect on women with cancer is not clear.

I am left with the impression that, in low-income countries, the primary determinant for the use of chemotherapy in advanced breast cancer (either stage iv or metastatic) is the patient’s ability to pay for chemotherapy and not an anticipated improvement in life expectancy. Women and their families are often encouraged to purchase expensive chemotherapies in the private clinical (again by the treating physician), and I don’t think that they are given a realistic expectation of what can be achieved with those drugs. Unfortunately, most patients will die of their disease regardless, and they often leave behind a family in a worse financial state than it was before. To expand the use of expensive chemotherapies, drug companies offer incentives (such as paying for travel, accommodation, and conference fees) to medical oncologists in Latin America and Asia—practices that are now considered unethical by many in Canada and the United States. Many oncologists in low-income countries strive to adapt medical paradigms (new drugs and technologies) that are based on recent North American and European studies, but that are accessible to only a very few of the patients they treat. In contrast, unconventional drugs might, in some situations, serve a purpose in the oncology setting—that is, certain common inexpensive drugs could be repurposed for cancer therapy in the adjuvant or neoadjuvant setting. Examples include bisphosphonates13, statins14, and acetylsalicylic acid15. The benefit of those agents could be investigated in large cohort studies in highly populated countries such as India, the Philippines, and Bangladesh.

I would also include in the research agenda studies that document the use of chemotherapy (and other therapies) in various series of unselected breast cancer patients. Such studies should include patients with primary and recurrent disease. How often was chemotherapy given? What was the difference in life expectancy for patients receiving and not receiving chemotherapy? Outcomes of particular interest would be those in patients with stage iv or metastatic disease. Studies that document, in a thorough and reliable way, current clinical practice for breast and ovarian cancer could be simple and inexpensive and could provide useful information about patterns of practice in low-income countries, helping to determine how practice might be improved.

The Lancet authors call for better coordination of services and better communication between stakeholders, including donors, governments, nongovernmental organizations, physicians, and patient groups. They emphasize social justice, equity, and further emancipation of women as keys to change. An increased investment in cancer control by the “international community” should be encouraged, but vigilance is required to ensure that the goals of the physicians and the government agencies are aligned with those of the women with cancer. Outcomes should be evaluated to ensure wise investment.

CONFLICT OF INTEREST DISCLOSURES

I have read and understood Current Oncology’s policy on disclosing conflicts of interest, and I declare that I have none.

AUTHOR AFFILIATIONS

*Women’s College Research Institute, Women’s College Hospital, Toronto, ON..